2. HYPERTENSION :SHMS GUIDELINE
Prof. Sulaiman Al-Shammari
Department of Family & Community Medicine , College of Medicine King Saud University , Riyadh, Saudi Arabia

3. Why Should We be Interested in Hypertension?
1.High prevalence of HTN & preHTN & poor control
2.Lacking Public and professional awareness
3.Open market for all possible drugs
4.Public misconceptions Re HTN, Rx & herbs
5.Many professionals “schools” with diverse traditions
6.HTN not adequately recognized as life-long risk for
CRF, Stroke and MI

4. auth region year Prev % % Aware/ 13 27 ? 20.4 sys Saeed Riyadh
Or contr
Abo alfotoh
South-West
1996 11
Contr 20
Saeed
Riyadh 13
Awareness 27
Synnowo
Gasim
1996(94)
22-26 ?
Al-Nuzha
Nationwide
1998
20.4 sys

5. Prevalence, Awareness, Treatment and Control of High Blood Pressure in the US Adult NHANES
II III III
% (Phase 1) (Phase 2) KSA
Prevalence %
Awareness %?
Treated ?
Controlled %?
Burt V et al, Hypertension 1996 & Unpublished data NHLBI (NHANES III, Phase 2)
JNC-VII 2003
Hazmi 2001; Kalanta 2001; Warsy 1999; Wahid Saeed 1996& Al-Nozha 1997

6. Prevalence in some countries
Country
Prev %
Contr %
USA 18 34
Canada 22 16
Egypt 26 8
China 14 3

7. Worldwide
Worldwide
20% of adults
50% over 60 years

10. SHMS Clinical Guideline

11. Classification Normal < 120/ < 80 Prehypertension 120-139/80-89
Hypertension ; stage -1 : /90-99
Hypertension ; stage -2 : > 160+/ 100 +

12. Aims of Clinical Evaluation
Accurate Measurement of BP to establish the diagnosis of Hypertension.
Look for other risk factors.
Assess for Co morbidities.
Look for Target Organ Damage or associated clinical conditions.
Be alert for clues of secondary cause.
Thorough history, physical exam & simple tests.

13. History-1 General medical history; allergies, surgeries,…etc.
Hypertension: duration , medications.
Personal history of DM, Dyslipidemia, CAD.
Family history of hypertension, CAD, Dyslipidemia, DM.
Style of living: occupation, smoking, activities, eating habits.

14. History-2 Palpitations ,sweating, tremors; pheo.
Weight gain; cushings, hypothyroid.
Weight loss; hyperthyroid, DM, pheo.
Renal stones; Hyperparathyroidism, PKD.
Symptoms of TOD related to organ.

15. History-3 Drug history : NSAID.
Steroids; oral contraceptive pill, corticosteroids.
Nasal decongestants-ephedrine.
Appetite Supressants-phenylpropanolamine.
Street drugs; cocaine.
Tricyclic antidepressants.
Erythropoietin.
Cyclosporine and Tacrolimus.
Alcohol.
Drug withdrawal; Clonidine, Beta-blockers.
Licorice.
Herbs ( dietary supplements).
Their use is common.
Patient does not mention them
Dr. does not ask
Inoccent but some do raise BP-Ephedra, St John’s, ward.

16. Measurement of BP-1
A diagnosis of HTN is made on multiple (3)measurement made on several occasions.
Five minutes rest before measurement.
Patient position-sitting, standing if Elderly, DM, autonomic disturbance.
Appropriate cuff size.
Calibrated & validated device.
No exertion or smoking before measurement.
Two readings.
Patient;rest for 5 minutes, seated not examing table, feet on the ground, back on the chair,hand on armrest, no talking, refrain from smoking 1 hour before.
Observer; sit next to him, good hearing to see, good sight to see, functioning brain to remember the figures.
Equipment; cuff size,parralel to heart, inflate fast, deflate slowly, korotokov sound 5 for D BP.
Two reading minutes apart.
First visit; check both arm.
Standing if elderly, DM, autonomic disturbance.

17. Measurement of BP-2 Methods of BP measurements :
Clinic or office BP measurements.
Self BP measurements.
Ambulatory BP measurements.

18. Examination-1 General medical examination.
BP; at the first visit, in both arms, if discrepancy think of Coarctation, dissection. FU visit check BP in the higher arm.
BP in lower limb; discrepancy suggests Coarctation.
Pulse; at first visit, compare R & L arm, any radiafemoral delay.
Weight, Height, BMI, Waist Circumference.

19. Examination-2 Neck; raised JVP.
Heart ; displaced apex, normal sounds, added sounds, murmur.
Lung ; check for any rales or wheezes.
Abdomen; masses, striae .
Lower limbs; swellings, trophic changes, pulses.
Fundus examination.

20. Examination-3 Moon face, buffalo hump; Cushing. Hirsutism; Cushing.
Bruits; carotid or abdominal.
Exophthalmus; hyperthyroid.
Café au lait spots, neurofibromatosis; pheo.
Goitre.

21. Risk Factors -1 Levels of SBP and DBP.
Dyslipidemia :TC >250 mg/dl(6.5 mmol/L), LDL C>155 mg/dl(4 mmol/L), HDLC < 40 mg/dl(1mmol/L) in men,< 1.3 mmol/L in women.
DM.
Smoking.

22. Risk Factors -2 Age (men >55, women > 65).
Family history of Premature CVD (men < 55 women < 65).
Obesity (BMI 30 + kg/m2)-abdominal obesity( WC -M>102 cm, F>88 cm)
CRP >1 mg/dl

23. Target Organ Damage-1
Ultrasound or radiological evidence of atherosclerotic plaque.
Heart ; LVH.
Proteinuria or raised plasma creatinine.
Retinal arteries narrowing .

24. Associated Clinical Conditions
Cerebrovascular Disease (ischemic stroke, cerebral hemorrhage, TIA).
Heart disease; MI, angina, Coronary vascularization, CHF.
Renal disease; Cr. Men mg/dl, women mg/dl.
Vascular Disease (PAD, Dissecting aneurysm).
Advanced retinopathy; hemorrhage, exudates, papilledema.

25. Secondary Causes Chronic kidney disease. Renovascular disease.
Primary aldosteronism.
Pheochromocytoma.
Cushing’s syndrome and steroid therapy.
Coarctation of aorta.
Thyroid or parathyroid disease.
Drug therapy.
Sleep apnea.
Alcohol

26. Clues to Secondary Causes of HTN
Age of onset.
Poor response to therapy.
Significant Target organ Damage.
No family history of Hypertension.
Examinations clues.
Laboratory tests

27. Laboratory Investigation
Urine analysis.
CBC.-hematocrit.
Blood chemistry; electrolytes, sugar, lipids, creatinine.
Electrocardiogram.
Optional; urine albumin creatinine ratio, CRP.

28. Risk Stratification BP levels Risk factors, TOD, ACC average Low added
SBP<120 & DBP <80
normal
SBP or DBP
80-89
high normal
SBP or DBP
90-99
Stage 1
SBP or DBP
Stage 2
SBP180 - or DBP
110
Stage 3
Risk factors,
TOD, ACC
no risk factors
average
Low added
Moderate added
High added
1-2 risk factors except DM
Very high added
3 or more,TOD, DM
Moderate
added
ACC

29. Management Plan Establish Good patient Doctor relationship.
Educate patient & family on the consequences of hypertension.
Encourage Self monitoring.
BP goal.
Non pharmacological therapy.
Pharmacological therapy.

30. Life Style Modification
Stop smoking.
Lose weight if overweight.
No alcohol intake.
Reduce sodium intake to 110 mmol/day (2.4 g sodium or 6 g sodium chloride).
Maintain adequate dietary potassium, calcium, and magnesium intake.
Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat.
Regular physical activity: optimum minutes of moderate cardiorespiratory activity 3-5/week or more

31. In summation, JNC 7 places great emphasis on the need for early and aggressive hypertension management, stressing that hypertension is an important risk factor for CVD. JNC 7 points out that systolic BP is the more important component to control, and that this often requires multiple medications. Additionally, JNC 7 endorses community health programs that support therapeutic lifestyle changes. The report also recognizes the importance of the physician’s guidance and judgment in the successful management and prevention of high BP.1
Thank you for your participation in this presentation.
1. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:

32. The recommended goal for patients with diabetes or chronic kidney disease has been lowered to <130/80 mm Hg. (The lowered goal now aligns JNC 7 recommendations with those of the American Diabetes Association and the National Kidney Foundation.)1
Systolic BP is a better predictor of CVD and more difficult to control than diastolic blood pressure (DBP). If systolic BP is controlled, DBP will follow in virtually all patients (those older than 50 years). Thus, the primary focus should be on achieving systolic BP goal.1
1. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:

33. Antihypertensive therapy, in addition to diet and exercise, can help reduce CVD-related events, including myocardial infarction, stroke, and heart failure.1 The findings presented in this slide are based on a study published in the December 9, 2000, issue of the Lancet. The study provides an overview of randomized clinical trials evaluating the effects of BP agents on cardiovascular-related events.2
1. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:
2. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Lancet ;356:

34. Thiazide-type diuretics are usually recommended as first-line therapy, but JNC 7 does not focus primarily on which agents should be used first line, second line, and so forth. Rather, the guidelines emphasize that BP must be aggressively controlled, and this usually requires multiple medications.1
According to the guidelines, most patients with hypertension will require 2 or more antihypertensive medications to achieve BP goal. Specifically, as the algorithm shows, antihypertensive treatment options—including calcium channel blockers (CCB), angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), and beta blockers—may be warranted for an individual without compelling indications with stage 1 hypertension.1
JNC 7 also points out that at stage 2 hypertension, if BP is >20/10 mm Hg above goal, consideration should be given to initiating therapy with 2 drugs.1
(Note to presenter: more detail on compelling indications on the following slide.)
1. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:

35. This table outlines some of the compelling indications, such as high coronary disease risk and diabetes, that call for specific antihypertensive drug classes. It is important to note that CCBs are now among the agents recommended for patients with high coronary disease risk or diabetes.1
In general, the recommended multidrug treatment of hypertension is similar for all demographic groups, but hypertension is more prevalent and severe among African Americans. This patient group has proven to respond more favorably to diuretics or CCBs, compared with beta blockers, ACE inhibitors, or ARBs.1
1. Chobanian AV, Bakris GL, Black HR, et al, and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:

36. Statins PRIMARY PREVENTION 1) Total cholesterol > 5 mmol/l,
2) < 70 Y., and
3) 10 Y. CHD-R > 30%.
SECONDARY PREVENTION
2) < 75 Y., and
3) CV complication: -
(Coronary Heart Diseases, Peripheral Vascular Diseases, Non-hemorrhagic CerebroVascular Diseases, or Atherosclerotic renovascular diseases.)

37. Antiplatelet Therapy only when BP control has been achieved
For Primary Prevention:
Hypertensive patients above the age of 50 years and at high or very high absolute cardiovascular risk, or
Hypertensive patients with moderate increase in serum creatinine > 1.3 mg/dl i.e. > 107 mmol/L.
For Secondary Prevention:
Patients with post MI, ischemic stroke, angioplasty, or coronary bypass

38. When you need to question compliance
When the treatment response is judged inadequate,
the patient can be asked about compliance. If
the patient reports less than complete compliance, the
clinician can proceed with compliance interventions.
If the patient reports full compliance, problems with
the treatment itself can be considered along with
application of more sophisticated methods of measuring
compliance.

39. Forms of Non-compliance
Not having the prescription filled,
Taking the incorrect dose,
Taking the medication at the wrong time,
Not taking one or more doses,
Stopping the medication too soon,
Relying on herbal meds

40. How/Can we measure?
1• Pharmacological measures ( concentrations of drugs or using biological markers integrated into the tablets) (difficult)
2• Clinical measures: a) evaluation of promptness for appointments or b) the use of questionnaires
c) or taking the amount of side effects into account)
3• Physical measures ( pill counting )

41. Recommendations for Improving compliance using a multi-faceted approach
Understanding the reasons for these forms of non-compliance is of key importance to the successful development of potential programs and their implementation
- Simplify medication regimens to once daily dosing
Tailor pill-taking to fit patients’ daily habits
Encourage greater patient responsibility/autonomy in monitoring their BP management (including monitoring)
Coordinate with worksite health care givers to improve monitoring of adherence with pharmacological and lifestyle modification prescriptions
Educate patients and educate/involve patients’ families about their disease/treatment regimens
Minimize side-effects, make taking it more appealing
High standard educated and motivated health care providers,

42. Indications for specialist referral
1.Urgent treatment needed
2.Possible underlying cause
3.Therapeutic problems
4.Special situations
Other Indications

43. Many questions are awaiting answers.
Hypertension &Ramadan “Based on the scarce available data, the following recommendations can be reasonably made”
medical advice before fasting in order to adjust their medications, if needed.
management should be individualized in fasting patients.
emphasize compliance with non-pharmacological and pharmacological measures.
Diuretics are better avoided, especially in hot climates or to be administered in the early evening.
emergency should be treated appropriately regardless of fasting.
Many questions are awaiting answers.

44. Hypertension in the Elderly
Hypertension occurs in more than half of individuals aged 65 are HTN & poor control
Follow same Rx principles outlined for the general care of hypertension
Lower initial drug doses may be indicated to avoid symptoms
Standard doses and multiple drugs are needed in the majority of older people to reach appropriate BP targets

45. Hypertension in Pregnancy
Chronic hypertension
Preeclampsia-eclampsia: preeclampsia occur in 2-3%; and eclampsia in 5-6/10,000 pregnancies that progress beyond 20 weeks.
Preeclampsia Superimposed upon chronic hypertension or Renal Disease
Gestational hypertension (only during pregnancy): occur in 8-10% of nulliparous women
Transient hypertension (only after pregnancy)

46. Treatment during pregnancy
Shared care with obstetrician for proper evaluation
Lifestyle changes: restrict activity and exercise during pregnancy.
Weight reduction is not recommended.
Limit Sodium intake.
Methyldopa and  ß-blockers can be used. Be ware of the possible growth restriction
An alternative would be nifedipine
Diuretic are not usually used in pregnancy
ACEI and ARBare contraindicated. If a patient becomes pregnant while on these agents, she should have her medication changed.
The “cure” for preeclampsia is delivery
Anticonvulsive Therapy

47. Breast Feeding
All antihypertensives studied have been found in breast milk. Long-term neonatal effects have not been studied.
Methyldopa as a first-line oral agent is reasonable unless contraindicated, and then labetolol may become first-line therapy.
If the patient has renal disease, then calcium channel blockers are the drugs of choice.
ACE inhibitors and angiotensin II receptor antagonists should not be used due to neonatal renal effects.
Diuretics may decrease milk production.
Certain beta blockers are concentrated in breast milk (atenolol and metoprolol), while others are not (labetolol and propranolol).

48. Hypertension and the Pill
Oral contraception usually shifts the blood pressure moderately upwards, but hypertension appears in less than 5% of women (1% to 2%).
Stopping OC is an effective antihypertensive intervention in a clinical setting.
keeping careful check on women taking these pills.

49. المملكة العربية السعودية kingdom of Saudi Arabia
الهيئة السعودية للتخصصات الصحية Saudi Commission of Health Specialties'
الجمعية السعودية لرعاية ضغط الدم Saudi Hypertension Management Society
(SHMS)
ندعوكم للإنظمام إلى الجمعية كعضو
علما أن رسوم العضوية السنوية 200 ريال .
لمزيد من المعلومات يرجى الاتصال:
الموقع الإلكتروني للجمعية :
البريد الإلكتروني للجمعية